HEALTH IMPACTS OF CLIMATE CHANGE:

RESEARCH PRIORITIES
IN ASIA PACIFIC REGION

Budi Haryanto
Dept. of Environmental Health - FPH University of Indonesia
Research Center for Climate Change – University of Indonesia
 OUTLINE
 What we know?
 What we don’t know?

 What responses are needed?

 Potential research ideas in Asia

and Pacific region

WHAT WE KNOW?
 Cartogram: Emissions of greenhouse gases

Density-equalling cartogram. Countries scaled according to

cumulative emissions in billion tonnes carbon equivalent in 2002.
Patz, Gibbs, et al, 2007
 Cartogram: (Selected) health impacts of climate
change

Malnutrition > diarrhoea > malaria > floods

Density-equalling cartogram: Patz, Gibbs, et al, 2007.
WHO regions scaled according to estimated mortality (per million people) in the
year 2000. Based on burden-of-disease attribution to the climate change that
occurred from 1970s to 2000 (McMichael et al., 2003).
 Global Dengue Epidemiology

1960s

Thousand-fold
increase in reported
incidence

1990s
Dengue fever only
DHF/DSS

Dengue007/CMH/260302
INCREASING TEMPERATURE AND MOSQUITO DEVELOPMENT
 Moderating Healtheffects
Health Effects
influences
Temperature-related
Temperature -related
illness and death
Extreme weather-
Extreme weatherstorms)
related (floods, -
related health effects
health effects
Environment
Air pollution-related
pollution -related
Impacts: health effects
Microbial changes:
Regional weather Contamination
Water
Water and
and food-borne
food -borne
changes Contamination paths
pathways
Climate diseases
diseases
Change
•Heat waves Transmission
Transmission dynamics
dynamics Vector -borne
Vector borne and
and
•Extreme weather rodent -
rodent borne diseases
borne diseases
•Temperature
••Precipitation
Changes in agro- Effects of food and
ecosystems, hydrology water shortages
•Sea-level rise

Socioeconomic and Mental, nutritional,

demographic disruption infectious-disease and
other effects
 Temperature effects on selected
vectors and vector-borne
pathogens
Vector
 Survival decrease/increase depending on the species
 Changes in the susceptibility of vectors to some
pathogens
 Changes in rate of vector population growth
 Changes in feeding rate and host contact

Pathogen
 Decreased extrinsic incubation period of pathogen in
vector at higher temperatures
 Changes in the transmission season
 Changes in distribution
 Decreased viral replication

Gubler et al. 2001

 Effects of changes in precipitation
on selected vector-borne
pathogens
Vector
• Increased rain may increase larval habitat
• Excess rain can eliminate habitat by flooding
• Low rainfall can create habitat by causing rivers to dry into
pools (dry season malaria)
• Decreased rain can increase container-breeding mosquitoes
by forcing increased water storage
• Epic rainfall events can synchronize vector host-seeking
and virus transmission
• Increased humidity increases vector survival and vise versa

Pathogen
• Few direct effects but some data on humidity effects on malarial
parasite development

Gubler et al. 2001

 Climate variability &
Dengue incidence
 Drought conditions: increase water storage
around houses  elevated Aedes aegypti
populations

 Enhanced breeding opportunities when

rainfall accumulates following drought

(Kuno et al. 1995)

 Estimated incidence of clinical malaria episodes (WHO)

Malaria

 40% world population at risk

 500 million severely ill
 Climate sensitive disease1
 No transmission where mosquitoes cannot survive

 Anopheles: optimal adult development 28-32ºC

 P falciparum transmission: 16-33ºC

 Highland malaria2
 Areas on the edges endemic regions

 Global warming  El Niño3

 Outbreaks

1
Atul et al. 2005; 2Patz et al. 2002; 3Haines et al. 2004
 Rodent-Borne disease
Rodent population climate sensitive1:
 Milder winters  increase survival
 Increased rain  increase food availability
 Flooding  decrease population size but increase contact
with humans
 Decreased rain  eliminate food and force rodents into
housing areas  increasing human contact
 Decreased rain  decrease population size

1
Gubler et al. 2001
 Leptospirosis related to water
and rodent contact

 Risk factors for Leptospirosis1

(data from large case control
studies)
– Water contact

– Exposure to carrier animals

(i.e. rodents)

 Outbreaks usually following

heavy rainfall or several weeks
after flooding  stagnant water

1
Levett, 2001; Tangkanakul et al. 2000; Ashford et al. 2000
 Water and food-borne diseases
Cholera:
• ↑ Sea surface temperature
associated with Cholera outbreaks1
– ↑ SST promotes algal blooms

– ↑ SST activates V. Cholerae

• El Niño strong related to outbreaks

1980-2001 Bangladesh2

Other:
• Relation cryptosporidium, heavy
rainfall3

1
Colwell et al. 1996; 2Rodo et al. 2002; 3Curriero et al. 2001
 15

INCREASING TEMPE-
RATURE IN JAKARTA
JANUAR
& SURABAYA Y
1900 - 2000

JULY
Surabaya : 1.46°C
Jakarta : 1.04°C

Surabaya : 3.29°C

Jakarta : 1.4°C
GLOBAL : 0.7°C/100 years
 RAINFALL TREND
IN INDONESIA 1950-2000
mm/Year
1800
1750
1700
1650
1600
1550
1500
1450
1400
1350
1950 1960 1970 1980 1990 2000

Year
Source: NOAA-CIRES (2005)
 IMPACTS CLIMATE CHANGE ON
HUMAN HEALTH IN INDONESIA
Direct effects:
• Increasing of injuries associated with extreme weather
events
Indirect effects:
• Increasing of vector borne diseases (malaria, dengue,
filariasis) associated with increasing of temperature,
rainfall, humidity, and vector density.
• Increasing of water borne diseases (diarrhea, cholera,
typhoid, leptospirosis) associated with decreasing of
water quality and water supply as well as floods and
droughts.
Indirect effects…
• Increasing of malnutrition cases is related to food
production and land use shifts
• Increasing of cardio cerebral vascular diseases,
hypertension, and mental disorders are associated with
urban stress, life style, displacements and conflicts.
• Increasing of influenza (ARI) and respiratory diseases
(asthma, pneumonia) are associated with increasing of
air pollution outdoor as well as indoor
• Increasing of food borne diseases is associated with
contamination, food handling, and poverty.
 INC ID ENC E RAT E & NUM BER OF
D IST RICT S/C IT IES W IT H D HF
IN INDONE S IA 1968- 2008
In c id enc e Rate p100,000
er # D is tric ts /Cities

80.00 400

70.00 350
INS IDE NS
60.00 300
K A B /K O TA TE RJA NGK IT
50.00 250

40.00 200

30.00 150

20.00 100

10.00 50

0.00 0
9681
196
1970
197
1972
1973
1974
1975
1976
197
1978
197
1980
198
1982
1983
1984
1985
1986
1987
198
198
190
19
192
193
194
195
196
197
198
19
20
201
20
203
204
205
206
207
208
209
Year
 TREND OF DHF IN JAKARTA

2003 2004 2005 2006

MAPPING MORBIDITY OF DHF IR < 100 cases per village

(INCIDENCE RATE - IR) IN DKI JAKARTA IR 100 - 200 cases per
(2003-2006) (per 100.000 population village
per village) IR > 200 cases per village
TREN
 Malaria Cases in
Indonesia 2000 - 2006
T rend of Confirmed Cases of M alaria
2000-2006

3.50

3.14
3.00
2.67
2.85
2.50

2.00

1.47
1.50
1.31
0.98 1.42
1.00

0.50

0.00
2000 2001 2002 2003 2004 2005 2006
TREND OF DIARRHEA CASES
IN INDONESIA 1985-2006
YEAR NUMBER OF CASES
(per 1000 Pop.)
1985 220
1986 280
2000 301
2003 374
2006 423
 Trend of Leptospirosis Cases
in Indonesia 2000 - 2007
270
240
210
180
150
120
90
60
30
0
2000 2001 2002 2003 2004 2005 2006 2007
DKI 0 0 138 65 78 62 51 248
Jabar 0 0 12 0 7 0 0 9
Jateng 0 0 0 12 40 34 35 48
Sulsel 0 0 0 0 18 9 2 16
DIY 0 0 0 0 20 8 0 3
Banten 0 0 0 0 0 0 0 34
WHAT WE DON’T
KNOW
Estimated population at risk of dengue
fever under “standard” climate change
scenario: 1990, 2085
1990

2085
.

Source. Hales S et al. Lancet (online) 6 August 2002.

 FRANK FENNER 1914-
2010
Microbiologist, Australian Academic of Science, Royal Society,
ANU, having studies evolution of every scale, from molecular
level to the ecosystem and planetary levels

 Evidence of global warming is in.

Our fate is sealed.
 We are going to be extinct.
Whatever we do now is too late.
 TEMPERATURE PROJECTION ON
INDONESIA
0
C 0
C
2 8 .0 2 8 .0

2 7 .0 2 7 .0

2 6 .0 2 6 .0

2 5 .0 2 5 .0

2 4 .0 2 4 .0
1950 1960 1970 1980 1990 2000 2000 2020 2040 2060 2080 2100

Year Year

Source: NOAA, 2002 Source: Susandi, 2005

 S k e n a r io K a su s D B D K o ta S u r a b a y a 2 0 0 7 - 2 0 1 5
PREDICTION OF DHF CASES IN SURABAYA 2007-2015
10000
9000 y = 1 2 0 30 .1.63 1e5 x
8000 R2 = 0 .2 0 1 1

7000
6000
5000
DBD

y = 3 6 0 .0 5 x + 8 9 4 .7 8
4000
R2 = 0 .3 3 2
3000
2000
1000
0
T a h u2n0 0 12 0 0 22 0 0 32 0 0 42 0 0 52 0 0 62 0 0 72 0 0 82 0 0 92 0 1 02 0 1 12 0 1 22 0 1 32 0 1 42 0 1 5
 S k e n a rio D B D 1 9 9 5 -2 0 1 5 P ro p D K I J a k a rta
PREDICTION OF DHF CASES IN JAKARTA 2007-
45000 2015
40000
2
y = 1 6 1 8 .4 x + 1 3 5 7 =.5 0;.5R9 3
35000

30000

25000
DBD

20000

15000

10000

5000

0
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
20
Tahun

YEAR
SEA LEVEL RISE SIMULATION
ON JAKARTA 2005-2065
 200
5

North
Source: Susandi et al, 2006
 201
0

Cilincing

Tanjung
Priok

North
Source: Susandi et al, 2006
 201
5

Cilincing

Koja
Tanjung
Priok Pademangan

North
Source: Susandi et al, 2006
 202
0

Cilincing

Koja
Tanjung
Priok Pademangan

North
Source: Susandi et al, 2006
 202
5

Cilincing

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Source: Susandi et al, 2006
 203
0

Cilincing

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Soekarno-Hatta
Airport

Source: Susandi et al, 2006

 203
5

Cilincing

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Soekarno-Hatta
Airport

Source: Susandi et al, 2006

 204
0

Cilincing

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Soekarno-Hatta
Airport

Source: Susandi et al, 2006

 204
5

Cilincing

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Soekarno-Hatta
Airport

Source: Susandi et al, 2006

 205
0

Cilincing

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Soekarno-Hatta
Airport

Source: Susandi et al, 2006

 206
5
National Monument
(2080?)

Cilincing BPPT (2065?)

Koja
Tanjung
Priok Pademangan

Penjaringan

North
Soekarno-Hatta
Airport

Source: Susandi et al, 2006

WHAT RESPONSES
ARE NEEDED?
December 17, 2009

Side event WHO:

Protecting Human
Health from Climate
Change
 WHO COPENHAGEN
2009 COMMITMENT
Protecting Human Health From
Climate Change:

 Top 10 actions for health

professionals
 Top 10 actions for national and

local policy-makers
 WHO top 10 actions for
health professionals
Global:
1. Advocate for a strong and equitable post-Kyoto agreement

2. Promote the need for a “health-oriented” agreement

National/Local:
3. Use your knowledge and authority to make the case for action

4. Assess your community and local health system’s capacities

to cope
5. Strengthen your health system’s adaptive capacity

6. Encourage your health institutions to lead by example

7. Champion the health benefits of greenhouse gas emission

reductions (mitigation)
 WHO top 10…
Personal:
8. Learn about climate-related health threats (
http://www.who.int/features/factfiles/climate_change/en/ind
)
9. Calculate and reduce your own carbon footprint (
http://actonco2.direct.gov.uk)
10. Promote these action points among your colleagues

Source: www.who.int/phe
POTENTIAL RESEARCH
IDEAS FOR ASIA AND
PACIFIC REGION
Climate Change and Health
Dual Purpose of Research
Enhance Health Protection, at two
levels:
1. Recognition of health risks will potentiate true (primary
prevention) – i.e. the reduction of GHG emissions.
(Which may also revitalise Health Promotion)
2. Health risks already exist and more are unavoidable.
So, we must develop and evaluate adaptive (secondary
prevention) strategies.
 Climate Change & Health:
‘Core’ Categories of Research
Empirical data- Scenario-based future-
based studies health risk assessment

1. Learn: 2. Detect 4. Predictive estimation

CC-health impacts (eg, modelling)
relations 3. Estimate
current burden

Past Present Future

Adaptive strategies
McMichael ‘07
PRIORITIES FOR CLIMATE CHANGE-
RELATED HEALTH RESEARCH

 Severity of potential impact or degree of

potential benefit
 Immediacy or required intervention or
response
 Need to change current intervention or
practicality of intervention

NCCARF, 2009
 MAJOR RESEARCH IN
RELATION TO HEALTH RISKS

1. Environmental effects
2. Impacts on community/social environment
3. Infrastructure and services

NCCARF, 2009
1. RESEARCH ON ENVIRONMENTAL
EFFECTS
 Extreme events:
Cyclone/storms/floods; bushfires; drought; and heat

 Change in natural systems:

Water supply/quality/water-borne disease;
Air quality, pollution, respiratory diseases, UV exposure;
Vector-borne and zoonotic diseases;
Food-producing systems (food safety, quality, supply)

NCCARF, 2009
2. RESEARCH ON IMPACTS
ON COMMUNITY/SOCIAL ENVIRONMENT

 Lifestyle impacts/social dislocation

 Impact on determinants of mental health
 Adverse community effects

NCCARF, 2009
3. RESEARCH ON
INFRASTRUCTURE AND SERVICES
 Essential services: coping capacity of hospitals or
health services; urban and building design;
disaster preparedness
 Economic (cost-benefit analysis of adaptive
strategies
 Evaluation of adaptive strategies
 Health data systems

NCCARF, 2009
 Methods of Assessing
Potential Health Impacts of
Climate Change
Analogue studies
Empirical/statistical:
• Analogue of a warming trend. e.g. increased malaria in highland region correlated with a
local trend in warming.
• Analogue of extreme events. e.g. assessment of the mortality impact of a heatwave.
• Description of basic or recurrent climate/health relationships. e.g. interannual variation in
malaria correlated with minimum seasonal temperature using time series data.

Predictive models
Empirical-statistical models:
• Extrapolation of simple climate/disease relationship using univariate regression, e.g. daily
temperature and mortality.
• Extrapolation of climate/vector/disease relationship using mapping and statistical
methods for use with spatially correlated data. e.g. mapping tick abundance with climate
and other variables.

Process-based or biological models:

• Models derived from accepted theory can be applied universally. e.g. forecasting changes
in areas suitable for vector-borne disease transmission using a vectorial capacity model.
• Integrated assessment models Multidisciplinary process-based and/or empirical-statistical
models linked together horizontally or vertically. e.g. impact of climate change on food
supply and risk of hunger.

Source: McMichael and Kovats, 2000a

 DO WE READY FOR
TAKING ACTION TO SAVE
OUR EARTH?
Thanks kindly for
your attention